Summary Report for FSPSAs Initiated During the Report Period Center: 54
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 01/01/09 and 03/31/09 Date of Report: 05-18-09 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.64 $208.79 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 5.64 $208.79 $37.00
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Subtotal (Total Children Is Unduplicated) 2 3 12.29 $417.57 $33.99
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 30 31 30.58 $1834.76 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 24.14 $2887.49 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 7 7.14 $346.43 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 30 30.00 $1455.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 11 11.14 $540.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 16.00 $776.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 65 66 75.14 $3644.43 $48.50
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Subtotal (Total Children Is Unduplicated) 132 180 198.15 $11828.14 $59.69
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 11.38 $569.05 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 6 4.93 $246.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.87 $46.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 55 56 75.57 $3778.64 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 5.72 $142.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 27 36.51 $1825.36 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 16 16.40 $820.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.02 $0.56 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 50 69.87 $3493.46 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.38 $34.58 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 74.29 $928.57 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 121 132 770.80 $38540.01 $50.00
INTR -INTR INTERPRETER 11 11 121.14 $6057.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 44 47 334.82 $22727.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 35.36 $1920.85 $54.32
PHY -97110 PT SESSION BY LICENSED PT 45 47 233.65 $15860.47 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 15.39 $836.14 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 15 13.50 $13.50 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 4 4 2.54 $47.63 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 6.43 $321.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 87 89 530.28 $35995.35 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 20.57 $271.54 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 196 291 44351.14 $22175.57 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 17.14 $857.14 $50.00
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Subtotal (Total Children Is Unduplicated) 269 827 46753.71 $158565.21 $3.39
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Total 1010 46964.15 $170810.93 $3.64
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Number of Children (Unduplicated) With at Least One Authorization 290